Noninvasive assessment of cerebrovascular disease

Coronary artery disease is highly prevalent among patients with premature peripheral vascular disease

PURPOSE

This study was designed to document the prevalence of coronary artery disease (CAD) and associated cardiac complications among patients with symptoms of premature peripheral vascular disease.

METHODS

We studied the peripheral and coronary arterial circulations of 59 consecutive male military veterans diagnosed with premature peripheral vascular disease (age of onset < or = 45 years) affecting the lower extremity. Patients who had not previously undergone coronary angiography underwent exercise stress testing. Patients unable to perform exercise testing and those with abnormal exercise test results underwent coronary angiography.

RESULTS

There was no evidence of CAD in 16 patients (29%) on the basis of normal exercise test results (n = 12) or normal coronary angiography results (n = 4). Forty-three patients (71%) had significant (> or = 50% lesion) CAD by coronary catheterization. Cardiac complications were frequent among the 43 patients. Eleven (65%) of the 17 patients with single-vessel CAD had previously documented myocardial infarctions, as did three (75%) of the four patients with two-vessel CAD and 18 (82%) of the 22 patients with three vessel or greater CAD. Three (18%) patients with one-vessel CAD had undergone coronary artery bypass grafting or percutaneous transluminal coronary angioplasty for symptoms, as had one patient (25%) with two-vessel CAD and 19 patients (86%) with three-vessel or greater CAD. Five patients died during the study period, four of myocardial infarction and one of stroke.

CONCLUSIONS

Premature peripheral atherosclerosis is associated with a high prevalence of CAD. Detection of CAD is important in this group, because cardiac complications are frequent.

Impact of duplex scanning on carotid endarterectomy

Duplex ultrasound permits safe and accurate assessment of the extracranial vasculature. This paper reports the change in patterns of referral to a specialized vascular unit following its introduction; increased referrals were seen in all specialties except neurology. A widely available and reliable duplex service has revealed more extracranial vascular disease than was previously recognized, and has increased referrals for carotid endarterectomy, thereby increasing surgical workload.

Natural history of nonoperated, significant carotid stenosis

One-hundred sixty-seven patients with 190 carotid arteries (109 asymptomatic) demonstrating 50-99% stenosis by arteriography (80), duplex scanning, or other noninvasive techniques were followed from 1-84 months (mean 24.2) for evidence of brain infarct, transient ischemic attacks, or vertebrobasilar symptoms. Thirty-nine arteries (20.5%) were symptomatic at last follow-up, including 13 (6.8%) producing ipsilateral strokes. Twenty-eight sides underwent carotid endarterectomy, 16 for symptomatic lesions at a mean interval of 14.5 months after the initial diagnostic study, with no neurologic deficit. Twenty-seven patients (16.2%) died, eight from stroke (30%), and 12 from cardiac causes (44%). In initially symptomatic sides, the incidence of any subsequent neurologic event (28.7%) or stroke/transient ischemic attack (25%) was significantly greater than in asymptomatic arteries (14.6% and 12%, respectively) (p less than .05). Carotid arteries with greater than 80% stenosis by arteriography and duplex scanning had a 46% incidence of further symptoms and 41.6% stroke/transient ischemic attack rate compared to 19.6% and 15%, respectively, in arteries with less than 80% stenosis (p less than .01). Cumulative life table analysis at 12, 24 and 36 months showed greater than 80% stenosed arteries to have stroke/transient ischemic attack free rates of 69%, 50.5%, and 21.6% compared to 91%, 83.7%, and 76% for arteries with less than 80% stenosis (p less than .05). At a mean follow-up of over two years, nonoperated carotid stenosis (greater than 50%) carries a 20.5% risk of neurologic symptoms and a 6.8% risk of stroke, 61.5% of strokes being fatal. Symptomatic carotid stenosis had a significantly greater incidence of ensuing neurologic events than asymptomatic arteries.(ABSTRACT TRUNCATED AT 250 WORDS)